Causes for hospitalizations at upazila health
complexes in Bangladesh.

Abstract:

Morbidity and mortality data are important for planning and
implementing healthcare strategies of a country. To understand the major
causes for hospitalizations in rural Bangladesh, demographic and
clinical data were collected from the hospital-records of five
government-run rural health facilities (upazila health complexes)
situated at different geographical regions of the country from January
1997 to December 2001. During this period, 75,598 hospital admissions in
total were recorded, of which 54% were for male, and 46% were for
female. Of all the admissions, diarrhoeal disease was the leading cause
for hospitalization (25.1%), followed by injuries (17.7%), respiratory
tract diseases (12.6%), diseases of the gastrointestinal tract (10.5%),
obstetric and gynaecological causes (8.5%), and febrile illnesses
(6.7%). A considerable proportion (8.3%) of the hospitalized patients
remained undiagnosed. Despite the limitations of hospital-based data,
this paper gives a reasonable insight of the important causes for
hospitalizations in upazila health complexes that may guide the
policy-makers in strengthening and prioritizing the healthcare needs at
the upazila level in Bangladesh.

The health status of people of a nation is reflected by their
morbidity and mortality patterns. The information is important for
planning and implementing healthcare strategies and for monitoring
healthcare services of the country (1-3). In many developing countries,
accurate population-based morbidity data are largely deficient or absent
(4). This may also be true for Bangladesh. The country is inhabited by
nearly 125 million people (5) and is divided into 507 administrative
units called upazila (subdistrict), with an average population of
~200,000 in each subdistrict (6). More than 80% of the people of
Bangladesh live in rural areas (5).

The Government provides healthcare services to its rural people
through health facilities called upazila health complex (UHC) at the
upazila level and through union subcentres at the union level (smallest
administrative unit). Many non-governmental organizations (NGOs) also
provide healthcare services through community clinics and similar other
establishments (7,8). In addition, the informal sectors provide
healthcare services at the village level (9). In the government
healthcare-delivery systems at the upazila level, there are 460
UHCs--each with 31 beds--to provide inpatient care to its population
(8). It also provides outpatient care, primary healthcare,
family-planning services, and other preventive healthcare services to
its population (8,10). Each UHC provides healthcare services to a
population of about 100,000 to 400,000 depending on its size (8). In
terms of service-delivery, the UHCs represent 31% of the government
health sector, signifying their importance as a major contributor to
healthcare service in Bangladesh (8). The UHCs are also the referral
centres for a number of grassroots-level community clinics (10). Medical
graduates, along with the paramedics and nurses supported by personnel
for laboratory services and supplies, are responsible for healthcare
services provided by the UHC (10).

Each UHC follows a disease-reporting system as recommended by the
Ministry of Health and Family Welfare, Government of Bangladesh. In the
absence of adequate diagnostic facilities, clinical evaluations of
patients conducted by the attending physicians are the mainstay of
diagnosis of illness. However, information collected by the system is
not very often analyzed for useful purpose. Therefore, very little
information is available on the major causes for hospitalizations at the
UHCs in Bangladesh for the policy-makers to prioritize the healthcare
needs at the upazila level.

In most communications, we have morbidity data that are derived
either by a community survey or by a survey on outdoor patients
attending the health facilities. In this paper, we have attempted to
understand the major causes for hospitalizations in different age-groups
and in both male and female in rural health facilities to guide the
policy-makers in strengthening and prioritizing healthcare needs at the
upazila level that would benefit the rural community in Bangladesh.

MATERIALS AND METHODS

During January 1997-December 2001, while conducting cholera
surveillance at five UHCs, surveillance physicians from the Epidemic
Control Preparedness Unit of ICDDR,B (International Centre for
Diarrhoeal Disease Research, Bangladesh) collected data from
hospital-registers on all hospitalized patients. The different locations
of the upazilas (subdistricts) are shown in Figure 1. Data collected
included demographic information and clinical diagnosis made by the
attending physician. Data collected were later entered into a
microcomputer and validated by double entry and logical checks. The
compiled data of categorized causes for hospitalizations presented in
this study are essentially similar to those of the disease-reporting
system available at the UHC. We followed the age-group classifications
that were in use at the UHCs for reporting different illnesses to the
district level during the above time period. The differences in the
proportion of different causes for hospitalizations between two groups
were done by the chi-square test.

RESULTS

In total, 75,598 hospital admissions were recorded in five UHCs
during the five-year period (1997-2001). The annual hospitalization rate
was 7.7 per 1,000 people (range 4-14 per 1,000 people per year). Of the
total number of hospitalizations, 54% were male, and 46% were female.
More than one-third of the admissions were from the union where the
health facility is situated. This observation was consistent for all the
five UHCs.

[FIGURE 1 OMITTED]

The causes for hospital admissions in broad categories are shown in
Table 1. Of all the causes, diarrhoeal disease was the leading cause for
hospitalization (25.1%), followed by injuries (17.7%), respiratory tract
diseases (12.6%), diseases of the gastrointestinal tract (10.5%),
obstetric and gynaecological causes (8.5%), and febrile illnesses
(6.7%). Over 8% of the hospitalized patients, however, remained
undiagnosed. Since obstetric and gynaecological causes are strictly
limited to female hospitalizations, we restricted our subsequent
analysis for the remaining five major causes that together accounted for
72.6% of the total number of hospitalizations. These were further
analyzed to see the distribution of their age and sex.

As injuries are rapidly becoming the leading cause of morbidity
among the people not only in developed countries but also in developing
countries, we analyzed the injury cases (Table 2) and found that
assaults of all types accounted for the majority (69%) of the admissions
from injuries while 9% of the admissions due to injuries were due to
road traffic accidents. A number of other injuries, such as suicides,
poisoning, drowning, domestic falls, animal and insect bites were
responsible for 22% of the admission due to injuries.

Table 3 shows the distribution of patients hospitalized due to the
five leading causes in different age-groups. In children aged less than
five years, diarrhoeal (50.9%) and respiratory diseases (41.5%)
accounted for 92.4% of all the leading causes for admissions in this
age-group. Among the older children (5-14 years), diarrhoeal diseases
alone accounted for almost 50% of the hospitalizations. The remaining
cases were due to other four causes (Table 3). In contrast, admissions
due to injuries in the age-group of 15-45 years accounted for 41.4% of
the admissions while diarrhoeal diseases and diseases of the
gastrointestinal tract each accounted for slightly over 22% of the
admissions in this age-group. Febrile illnesses accounted for 10.4% of
all the admissions in this age-group. In the age-group of over 45 years,
31.7% of all the admissions were due to injuries while diarrhoeal
diseases and diseases of the gastrointestinal tract accounted for 22.7%
and 22% of the admissions respectively. Admissions due to respiratory
diseases and febrile illnesses accounted for 12.8% and 10.8%
respectively in this age-group.

The distribution of the leading causes for hospitalizations by
gender is shown in Figure 2. The proportion of hospitalizations due to
injuries and respiratory diseases was significantly higher (p<0.001)
among males than among females. In contrast, the proportion of
hospitalizations due to diarrhoea and other gastrointestinal diseases
was significantly higher (p<0.001) among females. There was no
significant difference in the proportion of hospitalizations due to
febrile illnesses between males and females.

DISCUSSION

The findings showed that diarrhoeal diseases continue to be the
leading cause for hospitalizations in rural areas; watery diarrhoea and
acute respiratory infection (ARI) were the two major causes for
hospitalizations in children aged less than five years; injuries
requiring hospitalizations have become a major public-health concern,
especially among the adult rural population (aged 15 years and above);
and a high proportion of hospitalized patients remains undiagnosed.

In recent times, there has been a considerable decline in mortality
due to diarrhoeal diseases in Bangladesh (8,11-12). However, morbidity
due to the disease remains still high (13) that leads to the increased
need for hospitalization compared to other diseases as has been revealed
through this study. The delivery of message, particularly in the rural
community, that diarrhoea is a life-threatening disease and, in severe
form, may quickly cause deaths if not treated may explain the higher
proportion of hospitalizations due to the disease.

Several factors, such as improvement in primary healthcare
services, high coverage of Expanded Programme on Immunization (EPI),
widespread use of oral rehydration solution, and improvement in water
and sanitation conditions, have contributed to a marked reduction in
deaths of infants and children due to two major causes--diarrhoea and
respiratory infection (14). This information led us to think that
morbidity due to the above two diseases has also decreased. In contrast,
we have observed that more than 90% of the admissions among children
aged less than five years were due to watery diarrhoea and ARI,
reflecting the fact that they still remain as major causes of childhood
morbidity, particularly in rural areas. This observation is consistent
with the findings documented in a report of the World Health
Organization (13).

Morbidity, mortality, disabilities, and socioeconomic burden due to
injuries, such as road traffic accidents, burns, poisoning, suicides,
and assaults, have become the major public-health issues in countries of
the South-East Asia region (13). In this paper, injuries were the second
most common cause for hospitalizations, indicating that this health
problem is rapidly becoming the leading cause of morbidity among the
people not only in developed countries but also in developing countries.
The rate of hospitalization (17.7%) due to injuries of all types during
the period is consistent with the findings of a hospital-based study in
Bangladesh where 20% of all admissions were due to injuries (15).

The reason for such a high rate of hospitalization in rural areas
due to injuries is not clearly understood. We have shown that assaults
were the leading cause (69%) for hospitalization due to injuries. It is
known that, in rural areas of Bangladesh, the assault cases are largely
associated with dispute over ownership and demarcations of land. This
implication may have influenced the observed proportion of
hospitalization due to injuries. However, this notion could only be
clarified by a further study.

A considerable proportion (8.3%) of the admissions remained
undiagnosed. This could probably be due to the lack of having adequate
laboratory facilities at the rural health centres (16). Hospitalizations
due to surgical causes, cardiovascular diseases, and diseases of the
renal system and nervous system were only 6.7% of the total number of
admissions, and again, this could be linked to inadequate diagnostic and
treatment facilities at the health centres. This inadequacy at the
health facilities could also be responsible for the lower rate of
hospitalizations due to diseases, such as tuberculosis, enteric fever,
malaria, and nutrient deficiency disorders that are common in
Bangladesh.

The annual hospitalization rate in the healthcare facilities was
7.7 per 1,000 people, and more than one-third of the hospitalizations
were from the area where the health facilities are situated. Since we do
not have the information to explain this low annual hospitalization
rate, factors, such as distance of the health facilities from the place
of living and the expense associated, along with the cost of healthcare
services (17-20), could be responsible for this. The shortage of
essential drugs and unavailability of adequate diagnostic procedures
could also be responsible for such a low hospitalization rate (16).
Inequality in access to healthcare services between the rich and the
poor may also explain this situation (8).

Results of studies in different countries have demonstrated gender
inequalities in accessing to healthcare services (12,21-22). In
Bangladesh, women are less privileged in terms of access to healthcare
services than men, especially when they are subjected to violence
leading to physical injuries (8). However, the reasons for the observed
significant difference in hospital admissions due to the five major
causes between males and females were not explored

Limitations

Hospital-based data have some limitations that are more commonly
encountered in resource-poor settings, and all these could have affected
our study findings. In most cases, the healthcare services provided by
the Government in rural areas are being underused for various reasons.
Often there is lack of adequate information, and these are of poor
quality. Further, lack of adequate diagnostic tools at the upazila
health facilities might be responsible for missing more specific
diagnosis of the diseases.

Conclusions

Despite the limitations, this paper gives an insight of the
important causes for hospitalizations in the UHCs. In course of time
when there is widespread use of microcomputers, the individual UHCs will
be able to analyze their data on admitted patients in a more systematic
way to aid in the planning and evaluation of their services. However,
the information provided here is expected to help the policy-makers take
necessary measures in strengthening and prioritizing the healthcare
needs at the upazila health facilities in Bangladesh.

ACKNOWLEDGEMENTS

The study was partially funded by the National Institutes of Health
(Grant No. IROI A139129-01A1). ICDDR,B is supported by donor countries
and agencies, which provide unrestricted support for its operation and
research. Current donors providing unrestricted support include the
Australian Agency for International Development (AusAID), Government of
the People's Republic of Bangladesh, Canadian International
Development Agency (CIDA), Embassy of the Kingdom of The Netherlands
(EKN), Swedish International Development Cooperative Agency (Sida), and
the Department for International development (DFID), UK. The authors
gratefully acknowledge these donors for their support and commitment to
ICDDR,B's research effort.

The authors also express gratitude to the concerned upazila health
and family planning officers who extended their full cooperation by
providing with data. The assistance from other hospital staff of the
concerned health complexes is duly acknowledged. Finally, the authors
are indebted to those who reviewed the paper.

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